Helping Hands Healing Hearts 2012 Picnic Registration Form
By registering for the 2012 Annual Picnic, I understand that I, and those attending with me, may be photographed, interviewed and/or videotaped. I understand that these photos, interviews and/or video may be used in the future on the Helping Hands Healing Hearts website and/or for publicity and awareness
*
I AGREE
Contact Person
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
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Anguilla
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The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
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Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Please list all adults that will be attending. (Please include contact person)
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Parent
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Parent
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Parent
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Parent
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Parent
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Parent
Sibling
Other Relative
Other
Please list all non-heart children that will be attending.
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Sibling
Other Relative
Other
Full Name and Age
First Name
Last Name
Age
Relationship to Heart Child/Adult/Angel
Sibling
Other Relative
Other
Heart Survivors
Full Name and Age
First Name
Last Name
Age
Full Name and Age
First Name
Last Name
Age
Full Name and Age
First Name
Last Name
Age
Anything else we should know? (allergies, comments, etc.)
PayPal Registration Fees
Registration Fees
*
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Adults (13 yrs and up)
$10.00
$
10.00
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Kids (6-12yrs)
$5.00
$
5.00
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Children (5yrs and under)
Free
$
Free
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Heart Survivors
Free
$
Free
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$0.00
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